Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 800
Filtrar
2.
Einstein (Sao Paulo) ; 18: eAE5793, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-32520071

RESUMO

In December 2019, a series of patients with severe pneumonia were identified in Wuhan, Hubei province, China, who progressed to severe acute respiratory syndrome and acute respiratory distress syndrome. Subsequently, COVID-19 was attributed to a new betacoronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Approximately 20% of patients diagnosed as COVID-19 develop severe forms of the disease, including acute hypoxemic respiratory failure, severe acute respiratory syndrome, acute respiratory distress syndrome and acute renal failure and require intensive care. There is no randomized controlled clinical trial addressing potential therapies for patients with confirmed COVID-19 infection at the time of publishing these treatment recommendations. Therefore, these recommendations are based predominantly on the opinion of experts (level C of recommendation).


Assuntos
Betacoronavirus , Infecções por Coronavirus/diagnóstico , Unidades de Terapia Intensiva/normas , Pneumonia Viral/diagnóstico , Respiração Artificial/normas , Lista de Checagem , Infecções por Coronavirus/terapia , Estado Terminal , Humanos , Pandemias , Pneumonia Viral/terapia , Guias de Prática Clínica como Assunto , Respiração Artificial/métodos , Síndrome Respiratória Aguda Grave/diagnóstico , Síndrome Respiratória Aguda Grave/terapia
3.
Neumol. pediátr. (En línea) ; 15(2): 346-350, mayo 2020. tab, ilus
Artigo em Espanhol | LILACS | ID: biblio-1099683

RESUMO

The CoVID-19 pandemic may limit health resources in the hospital setting for the management of seriously ill patients, mainly adults; For this reason, strategies should be established from the pediatric field, which can consequently have an impact on the number of beds usually assigned to the child population. Of the patients who use prolonged mechanical ventilation, a significant number are managed at home, being considered to be at high risk of hospitalization and complications; on the other hand, there are some of them that remain institutionalized for clinical and / or social reasons. This article aims to provide guidelines for its safe handling both at home and in the pediatric services of our country, during times of pandemic CoVID - 19.


La pandemia de CoVID-19, puede limitar el recurso en salud en el escenario intrahospitalario para el manejo de pacientes graves, principalmente adultos; por lo cual se deben establecer estrategias desde el ámbito pediátrico, que pueden repercutir consecuentemente en los días camas destinados habitualmente a la población infantil. De los pacientes que emplean ventilación mecánica prolongada, un número importante es manejado en domicilio, siendo considerados de alto riesgo de hospitalización y complicaciones; por otro lado, existen algunos de ellos que permanecen institucionalizados por razones clínicas y/o sociales. Este artículo pretende entregar orientaciones para su manejo seguro, tanto en domicilio como en los servicios de pediatría de nuestro país, durante tiempos de pandemia CoVID ­ 19.


Assuntos
Humanos , Criança , Pneumonia Viral/terapia , Respiração Artificial/normas , Infecções por Coronavirus/terapia , Betacoronavirus , Respiração Artificial/métodos , Fatores de Tempo , Pandemias
4.
Monaldi Arch Chest Dis ; 90(1)2020 Mar 26.
Artigo em Inglês | MEDLINE | ID: mdl-32236089

RESUMO

Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR) On February 2020, Italy, especially the northern regions, was hit by an epidemic of the new SARS-Cov-2 coronavirus that spread from China between December 2019 and January 2020. The entire healthcare system had to respond promptly in a very short time to an exponential growth of the number of subjects affected by COVID-19 (Coronavirus disease 2019) with the need of semi-intensive and intensive care units.


Assuntos
Betacoronavirus , Infecções por Coronavirus/terapia , Controle de Infecções/métodos , Ventilação não Invasiva/métodos , Modalidades de Fisioterapia , Pneumonia Viral/etiologia , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório do Adulto/terapia , Insuficiência Respiratória/terapia , Terapia Respiratória/métodos , Infecções por Coronavirus/reabilitação , Cuidados Críticos , Dispneia/etiologia , Humanos , Hipóxia/complicações , Hipóxia/etiologia , Controle de Infecções/normas , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Itália , Ventilação não Invasiva/normas , Pandemias , Pneumonia Viral/reabilitação , Pneumonia Viral/terapia , Pronação , Respiração Artificial/normas , Síndrome do Desconforto Respiratório do Adulto/etiologia , Síndrome do Desconforto Respiratório do Adulto/reabilitação , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/reabilitação , Dispositivos de Proteção Respiratória , Terapia Respiratória/normas
5.
Crit Care Med ; 48(6): e440-e469, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32224769

RESUMO

BACKGROUND: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed. METHODS: We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations. RESULTS: The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which four are best practice statements, nine are strong recommendations, and 35 are weak recommendations. No recommendation was provided for six questions. The topics were: 1) infection control, 2) laboratory diagnosis and specimens, 3) hemodynamic support, 4) ventilatory support, and 5) COVID-19 therapy. CONCLUSION: The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new evidence in further releases of these guidelines.


Assuntos
Infecções por Coronavirus/terapia , Unidades de Terapia Intensiva/organização & administração , Pneumonia Viral/terapia , Guias de Prática Clínica como Assunto/normas , Betacoronavirus , Estado Terminal , Técnicas e Procedimentos Diagnósticos/normas , Humanos , Controle de Infecções/métodos , Controle de Infecções/normas , Unidades de Terapia Intensiva/normas , Pandemias , Respiração Artificial/métodos , Respiração Artificial/normas , Choque/terapia
6.
Anesthesiology ; 132(6): 1317-1332, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32195705

RESUMO

The COVID-19 outbreak has led to 80,409 diagnosed cases and 3,012 deaths in mainland China based on the data released on March 4, 2020. Approximately 3.2% of patients with COVID-19 required intubation and invasive ventilation at some point in the disease course. Providing best practices regarding intubation and ventilation for an overwhelming number of patients with COVID-19 amid an enhanced risk of cross-infection is a daunting undertaking. The authors presented the experience of caring for the critically ill patients with COVID-19 in Wuhan. It is extremely important to follow strict self-protection precautions. Timely, but not premature, intubation is crucial to counter a progressively enlarging oxygen debt despite high-flow oxygen therapy and bilevel positive airway pressure ventilation. Thorough preparation, satisfactory preoxygenation, modified rapid sequence induction, and rapid intubation using a video laryngoscope are widely used intubation strategies in Wuhan. Lung-protective ventilation, prone position ventilation, and adequate sedation and analgesia are essential components of ventilation management.


Assuntos
Infecções por Coronavirus , Transmissão de Doença Infecciosa/prevenção & controle , Intubação Intratraqueal/normas , Pandemias , Pneumonia Viral , Respiração Artificial/normas , China , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Hospitais/normas , Humanos , Pandemias/prevenção & controle , Seleção de Pacientes , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão
7.
Am J Respir Crit Care Med ; 201(7): 823-831, 2020 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-32023081

RESUMO

Rationale: Patients receiving prolonged mechanical ventilation experience low survival rates and incur high healthcare costs. However, little is known about how to optimally organize and manage their care.Objectives: To identify a set of effective care practices for patients receiving prolonged mechanical ventilation.Methods: We performed a focused ethnographic evaluation at eight long-term acute care hospitals in the United States ranking in either the lowest or highest quartile of risk-adjusted mortality in at least four of the five years between 2007 and 2011.Measurements and Main Results: We conducted 329 hours of direct observation, 196 interviews, and 39 episodes of job shadowing. Data were analyzed using thematic content analysis and a positive-negative deviance approach. We found that high- and low-performing hospitals differed substantially in their approach to care. High-performing hospitals actively promoted interdisciplinary communication and coordination using a range of organizational practices, including factors related to leadership (e.g., leaders who communicate a culture of quality improvement), staffing (e.g., lower nurse-to-patient ratios and ready availability of psychologists and spiritual care providers), care protocols (e.g., specific yet flexible respiratory therapy-driven weaning protocols), team meetings (e.g., interdisciplinary meetings that include direct care providers), and the physical plant (e.g., large workstations that allow groups to interact). These practices were believed to facilitate care that is simultaneously goal directed and responsive to individual patient needs, leading to more successful liberation from mechanical ventilation and improved survival.Conclusions: High-performing long-term acute care hospitals employ several organizational practices that may be helpful in improving care for patients receiving prolonged mechanical ventilation.


Assuntos
Assistência à Saúde/normas , Respiração Artificial/normas , Antropologia Cultural , Estado Terminal , Humanos , Fatores de Tempo , Estados Unidos
8.
Arch Dis Child Fetal Neonatal Ed ; 105(2): 209-214, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31201255

RESUMO

OBJECTIVE: There is a high incidence of preterm birth in low-income and middle-income countries where healthcare resources are often limited and may influence decision making. We aimed to explore the interplay between resource limitations and resuscitation practices for extremely preterm infants (EPIs) in neonatal intensive care units (NICUs) across the Philippines. METHODS: We conducted a national survey of NICUs in the Philippines. Institutions were classified according to sector (private/public), region and level. Respondents were asked about unit capacity, availability of ventilators and surfactant, resuscitation practices and estimated survival rates for EPIs of different gestational ages. RESULTS: Respondents from 103/228 hospitals completed the survey (response rate 45%). Public hospitals reported more commonly experiencing shortages of ventilators than private hospitals (85%vs23%, p<0.001). Surfactant was more likely to be available in city hospitals than regional/district hospitals (p<0.05) and in hospitals classified as Level III/IV than I/II (p<0.05). The financial capacity of parents was a major factor influencing treatment options. Survival rates for EPIs were estimated to be higher in private than public institutions. Resuscitation practice varied; active treatment was generally considered optional for EPIs from 25 weeks' gestation and usually provided after 27-28 weeks' gestation. CONCLUSION: Our survey revealed considerable disparities in NICU resource availability between different types of hospitals in the Philippines. Variation was observed between hospitals as to when resuscitation would be provided for EPIs. National guidelines may generate greater consistency of care yet would need to reflect the variable context for decisions in the Philippines.


Assuntos
Países em Desenvolvimento , Lactente Extremamente Prematuro , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Unidades de Terapia Intensiva Neonatal/normas , Ressuscitação/estatística & dados numéricos , Idade Gestacional , Alocação de Recursos para a Atenção à Saúde/normas , Alocação de Recursos para a Atenção à Saúde/estatística & dados numéricos , Gastos em Saúde , Hospitais Privados/normas , Hospitais Privados/estatística & dados numéricos , Hospitais Públicos/normas , Hospitais Públicos/estatística & dados numéricos , Humanos , Recém-Nascido , Recém-Nascido de muito Baixo Peso , Filipinas , Padrões de Prática Médica , Surfactantes Pulmonares/administração & dosagem , Respiração Artificial/normas , Respiração Artificial/estatística & dados numéricos , Ressuscitação/normas , Fatores Socioeconômicos , Análise de Sobrevida
9.
Rev Lat Am Enfermagem ; 27: e3215, 2019.
Artigo em Inglês, Português, Espanhol | MEDLINE | ID: mdl-31826158

RESUMO

OBJECTIVE: compare ventilatory time between patients with the application of a disconnection protocol, managed in a coordinated way between doctor and nurse, with patients managed exclusively by the doctor. METHOD: experimental pilot study before and after. Twenty-five patients requiring invasive mechanical ventilation for 24 hours or more were included, and the protocol-guided group was compared with the protocol-free group managed according to usual practice. RESULTS: by means of the multidisciplinary protocol, the time of invasive mechanical ventilation was reduced (141.94 ± 114.50 vs 113.18 ± 55.14; overall decrease of almost 29 hours), the time spent on weaning (24 hours vs 7.40 hours) and the numbers of reintubation (13% vs 0%) in comparison with the group in which the nurse did not participate. The time to weaning was shorter in the retrospective cohort (2 days vs. 5 days), as was the hospital stay (7 days vs. 9 days). CONCLUSION: the use of a multidisciplinary protocol reduces the duration of weaning, the total time of invasive mechanical ventilation and reintubations. The more active role of the nurse is a fundamental tool to obtain better results.


Assuntos
Respiração Artificial/normas , Desmame do Respirador/normas , Idoso , Protocolos Clínicos , Prática Clínica Baseada em Evidências , Feminino , Humanos , Masculino , Papel do Profissional de Enfermagem , Relações Médico-Enfermeiro , Projetos Piloto , Estudos Retrospectivos
10.
Crit Care ; 23(1): 424, 2019 12 27.
Artigo em Inglês | MEDLINE | ID: mdl-31881909

RESUMO

BACKGROUND: In patients with acute respiratory distress syndrome (ARDS), low tidal volume ventilation has been associated with reduced mortality. Driving pressure (tidal volume normalized to respiratory system compliance) may be an even stronger predictor of ARDS survival than tidal volume. We sought to study whether these associations hold true in acute respiratory failure patients without ARDS. METHODS: This is a retrospectively cohort analysis of mechanically ventilated adult patients admitted to ICUs from 12 hospitals over 2 years. We used natural language processing of chest radiograph reports and data from the electronic medical record to identify patients who had ARDS. We used multivariable logistic regression and generalized linear models to estimate associations between tidal volume, driving pressure, and respiratory system compliance with adjusted 30-day mortality using covariates of Acute Physiology Score (APS), Charlson Comorbidity Index (CCI), age, and PaO2/FiO2 ratio. RESULTS: We studied 2641 patients; 48% had ARDS (n = 1273). Patients with ARDS had higher mean APS (25 vs. 23, p < .001) but similar CCI (4 vs. 3, p = 0.6) scores. For non-ARDS patients, tidal volume was associated with increased adjusted mortality (OR 1.18 per 1 mL/kg PBW increase in tidal volume, CI 1.04 to 1.35, p = 0.010). We observed no association between driving pressure or respiratory compliance and mortality in patients without ARDS. In ARDS patients, both ΔP (OR1.1, CI 1.06-1.14, p < 0.001) and tidal volume (OR 1.17, CI 1.04-1.31, p = 0.007) were associated with mortality. CONCLUSIONS: In a large retrospective analysis of critically ill non-ARDS patients receiving mechanical ventilation, we found that tidal volume was associated with 30-day mortality, while driving pressure was not.


Assuntos
Respiração Artificial/mortalidade , Insuficiência Respiratória/fisiopatologia , Volume de Ventilação Pulmonar/fisiologia , Idoso , Estudos de Coortes , Feminino , Humanos , Idaho , Masculino , Pessoa de Meia-Idade , Respiração com Pressão Positiva/mortalidade , Respiração com Pressão Positiva/normas , Respiração Artificial/normas , Respiração Artificial/estatística & dados numéricos , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/terapia , Estudos Retrospectivos , Resultado do Tratamento , Utah
11.
Crit Care ; 23(1): 372, 2019 11 22.
Artigo em Inglês | MEDLINE | ID: mdl-31757222

RESUMO

BACKGROUND: Accurate volume assessment is crucial in children under fluid therapy. Over the last decade, respiratory variation of aortic peak velocity (△VPeak) has been applied in intensive care unit and surgeries to help clinicians guide fluid management. The aim of this systematic review and meta-analysis was to test diagnostic performance of △VPeak in predicting fluid responsiveness of ventilated children and to explore the potential factors that influence the accuracy of △VPeak. METHODS: We searched PubMed, Embase, and Cochrane from inception to April 2019 that evaluated association between △VPeak and fluid responsiveness after fluid challenge in children receiving mechanical ventilation. Data synthesis was performed within the bivariate mixed-effects regression model modified for synthesis of diagnostic test data. RESULTS: Eleven studies with a total of 302 pediatric patients were included in our meta-analysis. The pooled sensitivity and specificity of △VPeak was 0.89 (95%CI = 0.77 to 0.95) and 0.85 (95%CI = 0.77 to 0.91), respectively. The diagnostic odds ratio (DOR) of △VPeak was 48 (95%CI = 15 to 155). SROC yielded an area under the curve of 0.91 (95%CI = 0.88-0.93). The △VPeak cutoff value was nearly conically symmetrical distribution and varied from 7 to 20%. After excluding several extreme studies, most data were centered between 12 and 13%. The medium and mean cutoff values of △VPeak were 12.2% and 12.7%, respectively. In subgroup analysis, compared to total data analysis, △VPeak performed weaker in the younger children group (mean ages < 25 months), with lower area under the summary receiver operating characteristic curve (AUSROC) of 0.80 (0.76 to 0.83), but stronger in the older children group (mean ages > 25 months), with AUSROC of 0.96 (0.94 to 0.97). CONCLUSIONS: Overall, △VPeak has a good ability in predicting fluid responsiveness of children receiving mechanical ventilation, but this ability decreases in younger children (mean age < 25 months). The optimal threshold of △VPeak to predict fluid responsiveness in ventilated children is reliable between 12 and 13%. TRIAL REGISTRATION: The study protocol was registered prospectively on PROSPERO no. CRD42019129361.


Assuntos
Pressão Arterial/fisiologia , Respiração Artificial/métodos , Mecânica Respiratória/fisiologia , Volume Sistólico/fisiologia , Criança , Humanos , Valor Preditivo dos Testes , Respiração Artificial/normas
12.
Medicine (Baltimore) ; 98(42): e17534, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31626115

RESUMO

The knowledge of weaning ventilation period is fundamental to understand the causes and consequences of prolonged weaning. In 2007, an International Consensus Conference (ICC) defined a classification of weaning used worldwide. However, a new definition and classification of weaning (WIND) were suggested in 2017. The objective of this study was to compare the incidence and clinical relevance of weaning according to ICC and WIND classification in an intensive care unit (ICU) and establish which of the classifications fit better for severely ill patients. This study was a retrospective cohort study in an ICU in a tertiary University Hospital. Patient data, such as population characteristics, mechanical ventilation (MV) duration, weaning classification, mortality, SAPS 3, and death probability, were obtained from a medical records database of all patients, who were admitted to ICU between January 2016 and July 2017. Three hundred twenty-seven mechanically ventilated patients were analyzed. Using the ICC classification, 82% of the patients could not be classified, while 10%, 5%, and 3% were allocated in simple, difficult, and prolonged weaning, respectively. When WIND was used, 11%, 6%, 26%, and 57% of the patients were classified into short, difficult, prolonged, and no weaning groups, respectively. Patients without classification were sicker than those that could be classified by ICC. Using WIND, an increase in death probability, MV days, and tracheostomy rate was observed according to weaning difficult. Our results were able to find the clinical relevance of WIND classification, mainly in prolonged, no weaning, and severely ill patients. All mechanically ill patients were classified, even those sicker with tracheostomy and those that could not finish weaning, thereby enabling comparisons among different ICUs. Finally, it seems that the new classification fits better in the ICU routine, especially for more severe and prolonged weaning patients.


Assuntos
Estado Terminal/classificação , Unidades de Terapia Intensiva/normas , Respiração Artificial/normas , Desmame do Respirador/classificação , Brasil , Consenso , Estado Terminal/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Escala Psicológica Aguda Simplificada , Fatores de Tempo , Traqueostomia , Desmame do Respirador/normas
13.
Intensive Care Med ; 45(10): 1401-1412, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31576435

RESUMO

PURPOSE: To evaluate whether a perioperative open-lung ventilation strategy prevents postoperative pulmonary complications after elective on-pump cardiac surgery. METHODS: In a pragmatic, randomized, multicenter, controlled trial, we assigned patients planned for on-pump cardiac surgery to either a conventional ventilation strategy with no ventilation during cardiopulmonary bypass (CPB) and lower perioperative positive end-expiratory pressure (PEEP) levels (2 cm H2O) or an open-lung ventilation strategy that included maintaining ventilation during CPB along with perioperative recruitment maneuvers and higher PEEP levels (8 cm H2O). All study patients were ventilated with low-tidal volumes before and after CPB (6 to 8 ml/kg of predicted body weight). The primary end point was a composite of pulmonary complications occurring within the first 7 postoperative days. RESULTS: Among 493 randomized patients, 488 completed the study (mean age, 65.7 years; 360 (73.7%) men; 230 (47.1%) underwent isolated valve surgery). Postoperative pulmonary complications occurred in 133 of 243 patients (54.7%) assigned to open-lung ventilation and in 145 of 245 patients (59.2%) assigned to conventional ventilation (p = 0.32). Open-lung ventilation did not significantly reduce the use of high-flow nasal oxygenotherapy (8.6% vs 9.4%; p = 0.77), non-invasive ventilation (13.2% vs 15.5%; p = 0.46) or new invasive mechanical ventilation (0.8% vs 2.4%, p = 0.28). Mean alive ICU-free days at postoperative day 7 was 4.4 ± 1.3 days in the open-lung group vs 4.3 ± 1.3 days in the conventional group (mean difference, 0.1 ± 0.1 day, p = 0.51). Extra-pulmonary complications and adverse events did not significantly differ between groups. CONCLUSIONS: A perioperative open-lung ventilation including ventilation during CPB does not reduce the incidence of postoperative pulmonary complications as compared with usual care. This finding does not support the use of such a strategy in patients undergoing on-pump cardiac surgery. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT02866578. https://clinicaltrials.gov/ct2/show/NCT02866578.


Assuntos
Procedimentos Cirúrgicos Cardíacos/normas , Complicações Pós-Operatórias/etiologia , Respiração Artificial/normas , Resultado do Tratamento , Idoso , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Oxigenação por Membrana Extracorpórea/métodos , Feminino , França/epidemiologia , Humanos , Pulmão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Respiração com Pressão Positiva/métodos , Respiração com Pressão Positiva/normas , Respiração com Pressão Positiva/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Volume de Ventilação Pulmonar/fisiologia
14.
Einstein (Sao Paulo) ; 17(4): eAE4791, 2019.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31553359

RESUMO

Data collection for clinical research can be difficult, and electronic health record systems can facilitate this process. The aim of this study was to describe and evaluate the secondary use of electronic health records in data collection for an observational clinical study. We used Cerner Millennium®, an electronic health record software, following these steps: (1) data crossing between the study's case report forms and the electronic health record; (2) development of a manual collection method for data not recorded in Cerner Millennium®; (3) development of a study interface for automatic data collection in the electronic health records; (4) employee training; (5) data quality assessment; and (6) filling out the electronic case report form at the end of the study. Three case report forms were consolidated into the electronic case report form at the end of the study. Researchers performed daily qualitative and quantitative analyses of the data. Data were collected from 94 patients. In the first case report form, 76.5% of variables were obtained electronically, in the second, 95.5%, and in the third, 100%. The daily quality assessment of the whole process showed complete and correct data, widespread employee compliance and minimal interference in their practice. The secondary use of electronic health records is safe and effective, reduces manual labor, and provides data reliability. Anesthetic care and data collection may be done by the same professional.


Assuntos
Registros Eletrônicos de Saúde/normas , Controle de Formulários e Registros/métodos , Sistemas Computadorizados de Registros Médicos/normas , Anestesia Geral/normas , Confiabilidade dos Dados , Formulários como Assunto , Humanos , Complicações Pós-Operatórias , Estudos Prospectivos , Reprodutibilidade dos Testes , Respiração Artificial/normas , Procedimentos Cirúrgicos Robóticos/normas , Fatores de Tempo
16.
J Grad Med Educ ; 11(4): 389-401, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31440332

RESUMO

Background: Management of mechanical ventilation (MV) is an important and complex aspect of caring for critically ill patients. Management strategies and technical operation of the ventilator are key skills for physicians in training, as lack of expertise can lead to substantial patient harm. Objective: We performed a narrative review of the literature describing MV education in graduate medical education (GME) and identified best practices for training and assessment methods. Methods: We searched MEDLINE, PubMed, and Google Scholar for English-language, peer-reviewed articles describing MV education and assessment. We included articles from 2000 through July 2018 pertaining to MV education or training in GME. Results: Fifteen articles met inclusion criteria. Studies related to MV training in anesthesiology, emergency medicine, general surgery, and internal medicine residency programs, as well as subspecialty training in critical care medicine, pediatric critical care medicine, and pulmonary and critical care medicine. Nearly half of trainees assessed were dissatisfied with their MV education. Six studies evaluated educational interventions, all employing simulation as an educational strategy, although there was considerable heterogeneity in content. Most outcomes were assessed with multiple-choice knowledge testing; only 2 studies evaluated the care of actual patients after an educational intervention. Conclusions: There is a paucity of information describing MV education in GME. The available literature demonstrates that trainees are generally dissatisfied with MV training. Best practices include establishing MV-specific learning objectives and incorporating simulation. Next research steps include developing competency standards and validity evidence for assessment tools that can be utilized across MV educational curricula.


Assuntos
Competência Clínica/normas , Internato e Residência , Aprendizagem , Respiração Artificial/normas , Treinamento por Simulação/normas , Educação de Pós-Graduação em Medicina , Medicina de Emergência/educação , Humanos , Medicina Interna/educação , Médicos
17.
Crit Care Nurs Q ; 42(4): 392-399, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31449149

RESUMO

Mechanical ventilation is the primary supportive, invasive measure utilized in patients with acute respiratory distress syndrome. Throughout the years, many large multicenter randomized controlled trials and observational studies were analyzed to determine what ventilator parameters to use that would produce a mortality benefit after initial diagnosis. This article discusses the concepts of ventilator-induced lung injury, permissive hypercapnia, high-versus-low peep strategies, oxygenation goals, and recruitment strategies from a physiologic perspective and the major studies that produced recommendations for each. Newer concepts, such as driving pressure, are also discussed.


Assuntos
Respiração Artificial/normas , Síndrome do Desconforto Respiratório do Adulto/terapia , Lesão Pulmonar Induzida por Ventilação Mecânica/prevenção & controle , Ensaios Clínicos como Assunto/normas , Humanos , Hipercapnia/fisiopatologia , Hipóxia , Respiração Artificial/mortalidade , Volume de Ventilação Pulmonar/fisiologia
19.
BMC Urol ; 19(1): 61, 2019 Jul 05.
Artigo em Inglês | MEDLINE | ID: mdl-31277626

RESUMO

BACKGROUND: One of the greatest challenges presented with RIRS is the potential for movement of the stone within the operative field associated with diaphragm and chest respiratory excursions due to mechanical ventilation. To overcome this challenge, we propose in this pilot study a new general anesthesia technique combining high frequency jet ventilation (HFJV) with small volume mechanical ventilation (SVMV). Data regarding safety, feasibility and surgeons' impression was assessed. METHODS: Patients undergoing RIRS for kidney stones from November 2017 to May 2018 were prospectively recruited to participate in the study. In each case after the beginning of general anesthesia (GA) with mechanical ventilation (MV) surgeons were asked to assess the mobility of the operative field and conditions for laser lithotripsy according to the developed questionnaire scale. The questionnaire consisted of 5 degrees of assessment of kidney mobility and each question was scored from 1 to 5, 1 being very mobile (extremely poor conditions for dusting) and 5 completely immobile (Ideal conditions for dusting). After the assessment GA was modified with combined respiratory support (CRS), reducing tidal volume and respiratory rate (small volume mechanical ventilation, SVMV) and applying in the same time transcatheter high frequency jet ventilation (HFJV) inside the closed circuit. After beginning of CRS, surgeons were once again asked to assess the mobility of the operative field and the conditions for laser lithotripsy. Main ventilation parameters were recorded and compared in both regimens. RESULTS: A total of 38 patients were included in the study. The mean age was 49 (range 45-53) with a mean stone size of 10 mm (range 10-14) and Hounsfield unit of 1060 (range 930-1190). All patients underwent successful RIRS and no intraoperative complications occurred throughout the duration of the study. A statistically significant difference between ventilation parameters prior to and after CRS institution was detected in all cases, however their clinical impact was negligible. Despite this, assessment via the questionnaire scale point values varied significantly before and after the application of CRS and were 2.3 (2.1; 2.6) and 3.8 (3.7; 4.0) respectively (p < 0.001). CONCLUSIONS: The novel combined respiratory approach consisting of HFJV and SVMV appears to provide better conditions for stone dusting through reduced respiratory kidney motion and is not associated with adverse health effects or complications. TRIAL REGISTRATION: NCT03999255 , date of registration: 25th June 2019 (retrospectively registered).


Assuntos
Anestesia Geral/métodos , Cálculos Renais/cirurgia , Litotripsia/métodos , Respiração Artificial/métodos , Anestesia Geral/normas , Feminino , Humanos , Cálculos Renais/diagnóstico , Litotripsia/normas , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Respiração Artificial/normas
20.
Crit Care ; 23(1): 254, 2019 07 12.
Artigo em Inglês | MEDLINE | ID: mdl-31300012

RESUMO

BACKGROUND: Although low tidal volume is strongly recommended for acute respiratory distress syndrome (ARDS), whether or not the benefit varies according to the severity of ARDS remains unclear. This study aimed to investigate whether or not there is an interaction between low tidal volume and severity of ARDS. METHODS: This was a secondary analysis from a randomized controlled trial. The patients were subgrouped according to whether the PaO2/FiO2 (P/F) was > 150 or ≤ 150 mmHg on day 0. The interaction between a tidal volume of 6 mL/kg and the P/F was investigated in hierarchical chi-square analysis and logistic regression models. RESULTS: Eight hundred and thirty-six patients with ARDS were enrolled (345 in the high P/F subgroup [> 150 mmHg] and 491 in the low P/F subgroup [≤ 150 mmHg]). Compared to the traditional tidal volume group, the mortality of patients with low tidal volume was significantly lower in the high P/F subgroup (41/183 (22.4%) vs. 64/162 (39.5%), p = 0.001) but not in the low P/F subgroup (95/256 (37.1%) vs. 96/235 (40.8%), p = 0.414). In the hierarchical chi-square analysis, the test of homogeneity was significant (risk ratio of mortality 0.56 [0.40-0.79] vs. 0.91 [0.73-1.13], p = 0.018). In the multivariable logistic model, the odds ratio of mortality for the interacted item was significant (2.02, 95% confidence interval [CI] 1.06-3.86, p = 0.033). The odds ratio of mortality for low tidal volume was significant in the high P/F subgroup (0.42, 95% CI 0.24-0.72, p = 0.002) but not in the low P/F subgroup (0.89, 95% CI 0.60-1.31, p = 0.554). CONCLUSIONS: The benefits of low tidal volume ventilation remain uncertain in patients with severe ARDS. Further studies are needed to validate this significant interaction.


Assuntos
Respiração Artificial/métodos , Síndrome do Desconforto Respiratório do Adulto/terapia , Volume de Ventilação Pulmonar/fisiologia , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Respiração Artificial/normas , Síndrome do Desconforto Respiratório do Adulto/fisiopatologia , Estudos Retrospectivos , Índice de Gravidade de Doença
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA